I doubt she's talking about the same kind of critical thinking that philosophers are, and I find that definition abstract anyway. There’s been a lot of talk about critical thinking during our four years of nursing school, but our profs seem to have a hard time defining it. So I’ll go with a definition from Google.

Critical thinking can be seen as having two components: 1) a set of information and belief generating and processing skills, and 2) the habit, based on intellectual commitment, of using those skills to guide behaviour. It is thus to be contrasted with: 1) the mere acquisition and retention of information alone, because it involves a particular way in which information is sought and treated; 2) the mere possession of a set of skills, because it involves the continual use of them; and 3) the mere use of those skills ("as an exercise") without acceptance of their results.1

That’s basically rationality–epistemic, i.e. generating true beliefs, and instrumental, i.e. knowing how to use them to achieve what you want. Maybe part of me expected, implicitly, to have an easier time learning this skill because of my Less Wrong knowledge. And maybe I am more consciously aware of my mistakes, and the cognitive factors that caused them, than most of my classmates. When it’s forty-five minutes past the end of my shift and I’m still charting, I’m also calling myself out on succumbing to the planning fallacy. I once went through the first half hour of a shift during my pediatrics rotation thinking that one of my patients had cerebral palsy, when he actually had cystic fibrosis–all because I misread my prof’s handwriting as ‘CP’ when she’d written ‘CF’. I was totally confused by all the enzyme supplements on his list of meds, but it still took me a while to figure it out–a combination of priming and confirmation bias, taken to the next level.

But, overall, even if I know what I'm doing wrong, it hasn’t been easier to do things right. I have a hard time with the hospital environment, possibly because I’m the kind of person who ended up reading and posting on Less Wrong. My cognitive style leans towards Type 2 reasoning, in Keith Stanovich’s taxonomy–thorough, but slow. I like to understand things, on a deep level. I like knowing why I’m doing something, and I don’t trust my intuitions, the fast-and-dirty product of Type 1 reasoning. But Type 2 reasoning requires a lot of working memory, and humans aren’t known for that, which is the source of most of my frustration and nearly all of my errors–when working memory overload forces me to be a cognitive miser.

Still, for all the frustration, I’m pretty sure I’ve ended up in the perfect environment to learn this skill called ‘critical thinking.’ I’m way out of my depth–which I expected. No fourth year student is ready to work independently in a trauma ICU, but I decided to finish my schooling here in the name of tsuyoku naritai, and for all the days when I’ve gone home crying, it’s still worth it. I’m learning.

The skills

1.A set of information and belief generating and processing skills.

Medicine, and nursing, are a bit like physics, in that you need to generate true beliefs about systems that exist outside of you, and predict how they’re going to behave. This involves knowing a lot of abstract theory, which I’m good at, and a lot of heuristics and pattern-matching for applying the right bits of theory to particular patients, which I’m less good at. That’s partly an experience thing; my brain needs patterns to match to. But in general, I have decent mental models of my patients. I’m curious and I like to understand things. If I don’t know what part of the theories applies, I ask.

2.The habit, based on intellectual commitment, of using those skills to guide behaviour.

So you’ve got your mental model of your patient, your best understand of what’s actually going on, on a physiological and biochemical level, down under the skin where you can’t see it. You know what “normal” is for a variety of measures: vital signs, lung sounds, lab values, etc. Given that your patient is in the ICU, you know something’s abnormal, or they wouldn’t be there. Their diagnosis tells you what to expect, and you look at the results of your assessments and ask a couple of questions. One: is this what I expect, for this patient? Two: what do I need to do about it?

I’m not going to be surprised if a post-op patient has low hemoglobin. It’s information of a kind, telling the doctor whether or not the patient needs a transfusion, and how many units, but it’s not really new information, and a moderately abnormal value wouldn’t worry me or anyone else. If their hemoglobin keeps dropping; okay, they’re actively bleeding somewhere, that’s irritating, and possibly dangerous, and needs dealing with, but it’s not surprising.

But if a patient here for an abdominal surgery suddenly has decreased level of consciousness and their pupils aren’t reacting normally to light, I’m worried. There’s nothing in my mental model that says I should expect it. I notice I’m confused, and that confusion guides my behaviour; I call the doctor right away, because we need more information to update our collective mental model, information you can’t get just from observation, like a CT scan of the head. (Even this is optimistic–plenty of patients are admitted to the ICU because we have no idea what’s wrong with them, and are hoping to keep them alive long enough to find out.)

The basics of ICU nursing come down to treating numbers. Heart rate, blood pressure, oxygen saturations, urine output, etc; know the acceptable range, notice if they change, and use Treatment X to get them back where they’re supposed to be. Which doesn’t sound that hard. But implicit in ‘notice if they change’ is ‘figure out why they changed’, because that affects how you treat them, and implicit in that is a lot of background knowledge, which has to be put in context.

I’m, honestly, fairly terrible at this. It’s a compartmentalization thing. I don’t like using my knowledge as input arguments to generate new conclusions and then relying on those conclusions to treat human beings. It feels like guessing. Even though, back in high school, I never really needed to study for physics tests–if I understood what we’d learned, I could re-derive forgotten details from first principles. But hospital patients ended up in a non-overlapping magisterium in my head. In order for me to trust my knowledge, it has to have come directly from the lips of a teacher or experienced nurse.

My preceptor, who hates this. “She needs to continue to work on her critical thinking when it comes to caring for critically ill patients,” she wrote on my evaluation. “She knows the theory, and is now working to apply it to ICU nursing.” Shorthand for, she knows the theory, but getting her to apply it to ICU nursing is like pulling teeth. A number of our conversations have gone like this:

Me: “Our patient’s blood pressure dropped a bit.”

Her: “Yeah, it did. What do you want to do about it?”

Me: “I, uh, I don’t know... Should I increase the vasopressors?”

Her: “I don’t know, should you?”

Me: “Uh, maybe I should increase the phenylephrine to 40 mcg/min and see what happens. How long should I wait to see?”

Her: “You tell me.”

Me: “Well, let’s say it’ll take a few minutes for what’s in the tubing now to get pushed through, and it should take effect pretty quickly because it’s IV, like a minute... So if his blood pressure’s not up enough in five minutes, I’ll increase the phenyl to 60. Does that sound okay?”

Her: “It’s your decision to make."

Needless to say, I find this teaching method extremely stressful and scary, and I’m learning about ten times more than I would if she answered the questions I asked. Because “the mere acquisition and retention of information alone” isn’t my problem. I have a brain like an encyclopaedia. My problem, in the critical care nursing context, is the “particular way in which information is sought and treated.” I need to know the right time to notice something is wrong, the right place to look in my encyclopaedia, and the right way to take the information I just looked up and figure out what to do with it.

The mistakes

Some of my errors, unsurprisingly, boil down to a failure to override inappropriate Type 1 responses with Type 2 responses–in other words, not thinking about what I’m doing. But most of them are more of a mindware gap–I don’t yet have the “domain-specific knowledge sets” that the nurses around me have. Not just theory knowledge; I do have most of that; but the procedural habits of how to stay organized and prioritize and dump the contents of my working memory onto paper in a way that I can read them back later. Usually, when I make a mistake, I knew better, but the part of my brain that knew better was doing something else at the time, that small note of confusion getting lost in the general chaos.

Pretty much all nurses keep a “feuille de route”–I have yet to find a satisfactory English word for this, but it’s a personal sheet of paper, not legal charting, usually kept in a pocket, and used as an extended working memory. In med/surg, when I had four patients, I made a chart with four columns; name and personal information, medications, treatments/general plan for the day, and medical history; and as many rows as I had patients. If something was important, I circled it in red ink. This system doesn’t work in the ICU, so my current feuille de route has several aspects. I fold a piece of blank paper into four, and take notes from the previous shift report on one quarter of one side, or two quarters if it’s a long report. Across from that, I draw a vertical column of times, from 8:00 am to 6:00 pm (or 8:00 pm to 6:00 am). 7:00 pm and 7:00 am are shift change, so nothing else really gets done for that hour. I use this to scribble down what I need to get down during my twelve hours, and approximately when I want to do it, and I prioritize, i.e. from 1 to 5 most to least important. Once it’s done, I cross it off–then I can forget about it. On the other side of the paper, I make a cheat sheet for giving report to the next nurse, or presenting my patient to the doctors at rounds.

This might be low-tech and simple, but it takes a huge load off my working memory, and reduces my most frequent error, which is to get so overwhelmed and frazzled that my brain goes on strike. In other words, the failure to override Type 1 responses due to the lack of cognitive capacity to run a Type 2 process. It’s drastically cut down on the frequency of this mental conversation:

Me: “I turned off the sedation, and my patient isn’t waking up as fast as I expected. I notice I’m confused–”

My brain: “You’re always confused! Everything around here is intensely confusing! How am I supposed to use that as information?”

Odd as it might sound, I often don’t notice when my brain starts edging towards a meltdown. The feeling itself is quite recognizable, but the circumstances that lead to it, i.e. overloaded working memory, mean that I’m not usually paying attention to my own feelings.

“You need to stop and take a breath,” my preceptor says about fifty times a day. Easier said than done–but it’s more efficient, overall, to have a tiny part of my mind permanently on standby, keeping an eye on my emotions, noticing when the gears start to overheat. Then stop, take a breath, and let go of everything except the task at hand, trusting myself to have created enough cues in my environment to retrieve the other tasks, once I’m done. Humans don’t multitask well. Doing one thing while trying to remember a list of five others is intense multitasking, and it’s no wonder it’s exhausting.

The implications

“You can’t teach critical thinking,” my preceptor says, but I’m pretty sure that’s exactly what she’s doing right now. A great deal of what I already know is domain-specific to nursing, but most of what I’m learning right now is generally applicable. I’m learning the procedural skills to work through difficult problems, under what Keith Stanovich would call average rather than optimal conditions. Sitting in my own little bubble in front of a multiple choice exam–that’s optimal conditions. Trying to figure out if I should be surprised or worried about my patient’s increased heart rate, while simultaneously deciding whether or not I can ignore the ventilator alarm and whether I can finish giving my twelve o’clock antibiotic before I need to do twelve o’clock vitals–that’s not just average conditions, it’s under-duress conditions.

I’m hoping that after a few more weeks, or maybe a few more years, I’ll be able to perform comfortably in this intensely terrifying environment. And I’m hoping that some of the skills I learn will be general-purpose, for me at least. It’d be nice if they were teachable to others, too, but I think my preceptor might be right about one thing–you can’t teach this kind of critical thinking in the classroom. It's about moulding my brain into the right shape, and everyone's brain starts out in a different shape, so the mould has to be personalized.

But the habits are general ones. Notice when you're faced with a difficult problem, or making an important decision. Notice that you're doing this while distracted. Stop and take a breath. Get out a piece of paper. Figure out how the problem is formatted in your mind, and format it that way on the paper. (This is probably the hardest part). Dump your working memory and give yourself space to think. Prioritize from 1 to n. Keep an eye on the evolving situation, sure, but find that moment of concentration in the midst of chaos, and solve the problem.

Of course, it's far from guaranteed that this will work. I'm making an empirical prediction; that the skills I'm currently learning will be transferable to non-nursing areas, and that they'll make a difference in my life outside of work. I'll be on the lookout for examples, either of success or failure.

FWIW - My mom is a nursing instructor working on a PhD (her thesis topic is "Critical thinking in nursing," and she oversees a senior nursing practicum like what you describe!). I sent her this, and she said she wanted to show it to her students.

She also said she wanted to recruit you for her thesis research, if you're in our area :-P

Your interaction with your teachers is very similar to my experiences training more junior officers to stand "Officer of the Deck" on submarines (Officer of the Deck is the position ultimately in charge of everything having to do with the boat, internally and externally. Think of the role Picard or Riker assume when they sit in the "Captain's Chair" on the bridge in Star Trek. In real life people sleep and do other stuff so officers more junior than the CO/XO take on that role most of the time).

A lot of the same second guessing and reluctance to make decisions happens when people are training for this position. One small thing that makes a big difference in my experience is telling my students explicitly at the outset that I expect them to make decisions for themselves but I'll stop them if they're about to do something dangerous or horribly wrong. If one of the officers does something that's suboptimal but otherwise ok I'll let him see it through and we'll talk about it later. Even if your instructors haven't told you this explicitly I'd bet that they have a similar mindset. If you just internalize the fact that you'll be stopped before you do something extremely bad it might go a long way towards letting you relax enough to practice making quick judgements and acting on them.

Obviously if an instructor isn't around to stop you this advice is terrible.

This conversation sounds like a textbook example of guessing the teacher's password and it sounds like your preceptor is trying to tell you that the role you are taking — that of the student who is trying to figure out the "right" answer, which the teacher knows but is withholding — is inappropriate to the situation. Obviously this is not my domain of expertise, but I would suggest that any time you want to ask a "should I" question, you should instead be saying something like "I'm going to increase the vasopressors. Does that sound reasonable?" As you become more confident in your decisions you can leave off the second part.

Obviously this is not my domain of expertise, but I would suggest that any time you want to ask a "should I" question, you should instead be saying something like "I'm going to increase the vasopressors. Does that sound reasonable?"

This is exactly what she's explicitly told me I need to be doing!

I hadn't really thought of it as an example of "guessing the teacher's password", but I do know that I feel very uncomfortable applying my own judgement to real-life situations. Even though, if I saw that situation in the form of a written exam question, I wouldn't think it was very complicated or difficult. It's like part of me assumes that real life always has 10 million hidden variables that mean the obvious answer is never right...

if I saw that situation in the form of a written exam question, I wouldn't think it was very complicated or difficult.

This seems like a symptom of discrepancy between your belief (I know the right thing to do in this situation) and your alief (I am not qualified/experienced enough to know the right thing to do in this situation). Sort of like walking on a narrow ledge 3 feet off the ground vs walking on a narrow ledge 300 feet off the ground. I wonder if there are exercises to work explicitly on aligning one's alief with one's belief. Maybe jimmy can chime in.

I do know that I feel very uncomfortable applying my own judgement to real-life situations.

I think that this is, really, the central point. From what you've said here, you know a lot about nursing. If given an exam question detailing just about any set of circumstances, you'll probably be able to answer it correctly (given that, sometimes, the correct answer is 'call the doctor').

But now, let's look at consequences. If you answer an exam question wrong, writing down a course of action that's wrong, then the worst that will happen is a few stern words from a lecturer, and maybe a low mark. Nothing serious.

If you get something wrong in dealing with a patient, then there are serious consequences; and those consequences are serious to the patient, as opposed to yourself. Like a good nurse, you are extremely averse to having a patient take on serious consequences. So in real life, you don't just want the right answer; you want the right answer and a high level of certainty that it is, in fact, the right answer. What you're approaching your supervisor for isn't, it seems, the right answer - you have that already. What you are approaching your supervisor for is the certainty that your answer is actually correct.

And he won't give that to you, because he doesn't want to spend the rest of his life rubber-stamping your decisions; he wants you to develop the skill of knowing how certain you are that your course of action is correct, and he also wants you to develop a reasonable threshold of certainty, such that in all but the most difficult of situations you can continue without his help.

I agree that answering questions on an exam is a different skill from applying the knowledge in the field, almost in the same way that knowing the right thing is different from actually doing it. This is true even in software, where I generally have plenty of time to think about the right course of action. I can only imagine that it's way harder with the pressures of the ICU.

It sounds to me like your goal is to consistently override your Type 1 responses with better Type 2 responses. In an environment like nursing where you presumably have to make decisions quickly, I don't think you can make decisions quickly enough this way (cf. Blink). CFAR describes rationality not as the habit of overriding Type 1 responses but as the habit of improving communication between the Type 1 and Type 2 parts of your brain, which among other things improves your Type 1 responses.

There are lots of times when I use Type 1 responses, and they're perfectly appropriate and correct. Maybe this is even most of the time. A significant part of nursing is procedural knowledge learned until it becomes reflex. I don't have to think too hard about mixing IV meds anymore, and this is a good thing. In fact, wanting to have more developed and useful Type 1 responses is a big part of why I chose to study nursing, although I didn't have that vocabulary at the time.

But for self-improvement purposes, I can pretty much ignore what I do right and focus on what I do wrong. And the "critical thinking" aspect of nursing is one thing that I doubt ever becomes reflex. There's never going to be a point when I've seen every possible situation and know intuitively what's wrong with my patient, with their confusing and unexpected symptoms, without having to think about it.

I do expect it to get easier–partly because my theory knowledge will be more integrated, with more association chains to things I've actually seen in real life, and partly because right now I'm running a lot more than just critical thinking on Type 2. There are a ton more skills that will eventually become reflexes, but they haven't yet, and right now they're taking up a ton of working memory.

Also, I think it's a misconception that all decisions in nursing happen too quickly for Type 2 processes to be useful. Some things are very time-critical, but they tend to be the things that don't take a lot of thought anyway. If my patient gets accidentally disconnected from the ventilator, I really don't have to think very hard about whether or not I should reconnect them. It's basically a reflex. (I don't know who designed the tubing to get disconnected so easily.) If a patient goes into cardiac arrest, that's obviously very time-critical, and dealing with it is fairly complex–which is why their are procedures in place that we've been drilled on since first year, and algorithms for the doctors to follow so they don't have to think it out on the spot.

But quite a lot of complex problems aren't super time-critical. Usually it takes time for a patient's condition to change. The hard part is noticing early on, and knowing the difference between a not-important and an important change–whether or not stopping and figuring out what's going on is more of a priority than preparing meds and charting and changing dressings and all the other busywork of nursing. That's a skill that can probably be trained to the 5-second level. Once you've noticed that something confusing is going on, you do need to use Type 2 reasoning to figure out what and why.

The hard part is noticing early on, and knowing the difference between a not-important and an important change

Hmm. This sounds like it would be best done with a mix of Type 1 and Type 2 processes, e.g. Type 1 flags things for your attention and Type 2 assesses whether they actually deserve your attention, or something like that. But I'm not a domain expert.

I think you're right. The Type 1 flags come from a combination of theory and hands-on experience, and become reflexes quite early on. Mine work fairly well. The type 2 part, assessing whether or not it deserves your attention, seems to be to be about 10 million times harder for me, and is mostly what I'm trying to work on. I ask my preceptor "is this normal or should I be freaked out?" a lot. Of course, she rarely tells me straight up, and usually tries to make me reason through it on my own with a series of guiding questions.

Glad to hear that clarified. I've been using rationality to build up Type 1 responses since I found LessWrong, but there's still a lot of cultural baggage that tells me that intelligence/rationality is all about the Type 2 responses.

This seems oddly reminiscent of high-level video game competition; there's a lot going on, things can go horribly wrong at any moment, and you have to very quickly figure out what's important, what isn't, and what you need to do about it.

This reminds me of a conversation I had in the staffroom recently. Two nurses had been talking about some dragon-breeding game they both played on Facebook. I stopped paying attention to the conversation for a bit, and when I zoned back in, they were talking about how annoying it was to have to "restart their sled." I asked if this was something in their dragon-breeding game. They both laughed for a solid thirty seconds before correcting me–it was a dialysis machine. Apparently 'SLED' stands for 'sustained low-efficiency dialysis'. They said it would make the world's worst game.

But a critical care medicine or critical care nursing video game might actually be quite fun and exciting, for people who aren't already doing that stuff all day...

I am sure that you can get through this and learn to internalize Type 2 thinking as Type 1, and it will be of great help to you in general, but you will probably not be as good at it as those who are natural and don't get as stressed out when thinking under pressure. I'm wondering if down the road you would be better off finding a career which plays more to your strengths as a Type 2 thinker, while at the same time allowing you to express your need for altruism and compassion. From what I know, many ICU nurses operate close to breaking point and burn-out nearly all the time, one has to have a specific type of personality to thrive in such an environment.

Oh, I have no doubt that there are a dozen careers that would play more to my strengths than nursing. If I'd wanted to stay in my comfort zone, I would have gone into academia, like my parents. And maybe there are some aspects of nursing where I'll never be as good as the "naturals"–but I think you overestimate the number of "naturals" out there, and what percentage of nurses they represent. My preceptor, who makes everything look effortless now, confesses that she was scared shitless for the first year that she worked in ICU–and she did nursing as a second career, after a degree in biology, and had already worked as a nurse for a year in med/surg, acquiring the basic organization skills that I'm still working on.

For all the constructive criticism I've gotten, no one has suggested I find another career. Most of my teachers have told me clearly that they think I'm going to be an awesome nurse, once I get my feet under me. Being curious and conscientious and eager to learn new things and aware of the importance of deliberate rather than haphazard practice goes a long way. I tend to have a flatter learning curve than most people, when it comes to acquiring Type 1-ish skills–but I keep improving and end up just as good as everyone else. My parents might have told me when I was eleven that I ought to find a job that didn't involve working with people, since my social skills were spectacularly awful–but I worked on that, and today my nursing profs tell me that "interpersonal communication" is one of my strengths.

From what I know, many ICU nurses operate close to breaking point and burn-out nearly all the time, one has to have a specific type of personality to thrive in such an environment.

That sounds like a badly run ICU. In general, the place in a hospital where I'd most expect to see burnout is an understaffed surgery floor, maybe ortho–nurses looking after six to eight hip and knee surgery patients, overworked, bored because they've been having the same sort of patients for 10 years, and working with other nurses who are just as burnt out. My preceptor, who's worked in both areas, confirms this. The ICU where I'm placed right now is probably the least understaffed part of the hospital, and has the best teamwork, both amongst the nurses and with other health care professionals. Not to mention you get to have interesting patients.

(The idea of working in emerg scares me though. Not enough structure.)

Practice will make you better, but you might find yourself always struggling to achieve a level of minimal functionality. Even if you become a good nurse, you might never be as productive as you would have been if you had chosen a career more suited to your dispositions.

you might never be as productive as you would have been if you had chosen a career more suited to your dispositions. [...] Be aware of comparative advantage.

I would agree with this if I was better at math and physics. I maintained grades of around 90% in high school science classes, but that's by no means an indication of genius. I liked science, and was exposed to it from an early age through my parents, so a lot of concepts weren't new to me the way they were to my peers, and I was a conscientious, hard-working student. I certainly don't think I would have been more likely than any of my Grade 12 classmates to accomplish anything revolutionary in science.

don't do things just to differentiate yourself from your parents.

Ha, you noticed one of the unstated wrong reasons why I wanted to go to nursing school. Although the fact that my father was extremely unhappy in academics (for anxiety-related reasons) is good evidence that I wouldn't have done any better going straight into academic research, so I don't consider that a wrong reason.

but you might find yourself always struggling to achieve a level of minimal functionality.

"Minimal functionality" would be an excellent description of my performance as, say, a professional athlete or an musician/composer–both of which I at some point thought of pursuing as a career. I think I can achieve a lot better than that in nursing.

This comment bothers me for two reasons - one obvious, one not so obvious.

The first is that I think you're empirically wrong - I think Swimmer963 will make an excellent nurse. She is obviously way above the mean in both intelligence and determination, and there's not much more to success than that. When she says she is "terrible" at something, she is probably just being 1) modest and 2) self-critical - what she probably means is not that she's worse at it than the other people in her cohort, but that she realizes she can be a lot better at it. That kind of realization is the sine qua non of excellence.

More abstractly, I think your comment is problematic because it tends to undermine or second-guess a difficult choice that someone has made after the fact (in this case, Swimmer's decision to become a nurse). This is non-obvious from a rationalist standpoint, but you really shouldn't do that. The most obvious example situation is that you don't tell your friend that you think he was a fool to get married when he's already married - you can give him that kind of advice before the wedding, but not after. If Swimmer were asking for advice about what career to go into, it would be reasonable to suggest one area or antisuggest another, but she's already made her choice, so this kind of advice is not very helpful and may actually be harmful.